Phimosis

Background

The foreskin (also known as the prepuce) is a normal part of the penis that covers the glans (the head). The outer prepuce is keratinized (like the external skin) whereas the inner prepuce is a mucosal surface (like the inside of the mouth). The foreskin contains nerves and glandular tissues.

Phimosis is a normal physiologic finding in children. The foreskin is normally adeherent to the head of of the penis and gradually releases from the penis head over childhood. This is termed 'Physiologic Phimosis'. It should be noted that the timing of separation of the forskin from the glans and complete retractibility is highly variable. The ability to completely separate the foreskin from the glans or completely retract the skin is not a disease in pre-pubescent males and should not be classified as phimosis. Some doctors use the term 'physiologic phimosis' to distinguish this normal condition from 'pathologic phimosis'. Many children will not able to fully retract the skin until the teenage years. Ballooning of the foreskin and splaying of the urinary stream do not usually indicate phimosis and may occur in perfectly normal males.

Pathologic phimosis is a condition affecting uncircumcised males in which scarring of the foreskin produces a narrowing. The scarring may severe enough to block complete retraction of the skin over the head of the penis. This is different than paraphimosis - this is when the skin is pulled back over the head of the penis to expose the glans but cannot be replaced back over the penis.True phimosis is found in about 1 in 100 males at age 15, but most cases are 'physiological'. Post-pubescent males should be able to fully retract the foreskin for reasons of hygeine.

Causes

Many cases of phimosis in boys are idiopathic - which means that a specific cause cannot be identified.

True phimosis is often times due to an inflammatory condition called lichen sclerosis (LS) of the foreskin, also known as Balanitis Xerotica Obliterans. This condition may occur in any age group and the cause is not known (see below). In some cases, excessive force in trying to retract the foreskin leads to fissuring, bleeding and scarring. This vicious cycle tends to continue to the point where the self-induced scarring requires removal with circumcision.

In all age groups, recurrent inflammation and infection of the foreskin can result in scarring. Lichen sclerosus tends to make the skin like 'leather'. The skin becomes inelastic and easily fissures. This condition can be identified by the pale white appearance and firm feeling nature of the foreskin. It can progress onto the head of the penis and down the urethra producing significant problems with urination.

Diagnosis & Evaulation

History and physical examination is the primary diagnosis. As mentioned previously, ballooning of the foreskin and splaying of the urinary stream are not reliable symptoms of pathologic phimosis.

Significant aspects of symptomatic phimosis include recurrent urinary tract infections, infections of the foreskin or penis or trips to the emergency room as the child is unable to pee.

Treatment

it is not unusual for boys to have an unretractable foreskin until puberty. So long as they are not having issues with the foreskin, they can safely be observed. Some parents have difficulty leaving the non-diseased but not yet retractable foreskin alone - especially if the father or other males in the family have been circumcised. No attempt should be made to forcibly retract the foreskin or clean the area excessively with soap. Forcible retraction may produce fissuring and scarring, in which case surgery may be required.

Intervention may be undertaken if there are issues with any of the following

hygeine issues

recurrent inflammation or infection of the foreskin (balanoposthitis)

recurrent urinary tract infection

difficulty with urination

In deciding on the most appropriate treatment, the severity of the complications, the tightness of the foreskin and the presence of scarring (such as lichen sclerosus) are considered. if significant scarring and fissuring is present, a circumcision may be required. However, in most cases topical steroid and proper hygiene are the mainstays of therapy. Steroid cream softens the skin and makes it more elastic so that he can be retracted.

Steroid cream should be applied sparingly to the affected area and this is best done when the foreskin is retracted and the tight area easily identified. Typically this is done 2-3 times per day for a few months. Reassessment is usually undertaken to ensure the desired result has been achieved.

If conservative management fails or the degree of scarring is such that steroids will not be effective, than a circumcision can be performed.

Topical Creams for treatment of phimosis: Dosage and application technique

Topical Creams for Phimosis

Betamethasone 0.1% ointment (Betnovate, Celestone; 15 and 45 gram tube). Topical steroid. Usually applied to the foreskin 2-3 times per day. It may take a few months of application before a response is seen.

80% of children will respond to topical betamethasone when it is applied correctly 3 times per day for 8-12 weeks. The function of the steroid is to gradually thin the skin and make it stretchy. This aill allow the head of the penis to begin to dilate the foreskin as it is stretched over the head.

Application of the cream should be done with the foreskin retracted until it is tight and shiny. The cream is then applied to the foreskin. The foreskin should he held in the retracted position for 20 seconds to allow the head of the penis to gradually dilate the foreskin. THE SKIN SHOULD ALWAYS BE RETURNED TO THE RELAXED POSITION (NORMAL ANATOMIC POSITION) after the gentle retraction. Failure of return of the skin to the anatomic position can result in the skin becoming stuck behind the head of the penis (paraphimosis) which is an emergency.